Like the rest of the U.S. health care system, cancer centers are scrambling to react to the growing threat of coronavirus infection and COVID-19. A major area of concern is coronavirus testing, with many cancer centers developing their own diagnostic tests to find out results faster than sending patient samples to commercial laboratories.
The University of Pennsylvania’s Abramson Cancer Center in Philadelphia is telling patients to contact their oncologist to report any symptoms that raise concern about COVID-19, such as a fever. If the oncologist thinks testing is warranted, the Abramson Cancer Center staff have two coronavirus testing options to use at their discretion, says Lynn Schuchter, chief of hematology-oncology at the Abramson Cancer Center.
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For cancer patients who have symptoms but can wait a few days to know the results, the University of Pennsylvania sends samples to a commercial lab. The turnaround time is about a week. In cases where knowing if a patient is infected will impact current treatment decisions or if a patient is very sick, the hospital has developed its own test in their in-house molecular laboratory. This test has a turnaround time of just five hours, according to Schuchter. It is also being used to test health care providers with symptoms of COVID-19 so that if they test positive, they can isolate themselves right away to minimize exposure to patients and other clinicians.
“We’re fielding so many questions from our cancer patients [on coronavirus] in part because many primary care providers don’t feel comfortable giving recommendations to cancer patients about COVID-19 testing or treatment, as cancer patients are often already on complex treatments and may be immunocompromised,” says Schuchter.
According to the American Society of Clinical Oncology, there is no specific guidance for testing patients with cancer for COVID-19. Patients who feel they need to be tested should follow their local and state public health directives and guidance. The Centers for Disease Control and Prevention (CDC) does not mention cancer patients specifically in its guidance on prioritization for coronavirus testing. “Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested,” the CDC states.
“We are encouraging patients who have coronavirus symptoms to call their oncologist,” says Schuchter. For patients who test positive for the coronavirus, “we are prepared to handle them at the hospital in designated isolation rooms, because we do not want to send our patients to the emergency room.”
Schuchter adds that the hospital is working to minimize the number of cancer patients staying at the hospital overnight—which as of March 24 was 80 people—as well as the number of patients coming in for treatments, scans or evaluations. “We are being very cautious because we still don’t know if people with cancer are at more risk of complications associated with coronavirus.”
Moffitt Cancer Center in Tampa, Florida, initially sent their patients to testing sites in the community set up through BayCare Health System. But the sites were inundated with about 500 tests a day across the sites and had to be shut down when they ran out of tests, says John Greene, the chief of the division of infectious diseases at Moffitt. Moffitt then began sending their patients’ samples to Quest Diagnostics, but the turnaround time was more than two weeks in some cases, which led Moffitt to forge an informal partnership with a neighboring hospital, which has been running up to five tests a day for the cancer center.
Over the past three weeks, Moffitt’s molecular biology lab has been able to create their own diagnostic test and will be able to conduct about 14 tests per day by March 30, according to Greene.
Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, is also using an in-house COVID-19 test available through the Vanderbilt health system. The turnaround time fluctuates depending on how many samples are in the queue. “Because of demand, there have been national shortages of reagents that have impacted the number of tests that we can perform,” says Adam Seegmiller, director of laboratory medicine and hematopathology at the Vanderbilt University Medical Center.
“In the last week, the volume of samples to be processed has increased, and we were impacted by the availability of one of the reagents necessary to perform the test,” says John Howser, Vanderbilt’s chief communications officer.
For both commercial tests and those developed by cancer centers, the limiting factor for increasing testing has been availability of materials needed for testing. These materials—including swabs, as well as chemicals and other substances needed to conduct the laboratory test—are the same reagents used in other standard laboratory testing, such as viral titers for patients about to receive a bone marrow transplant. This means that labs need to prioritize the most important tests for each cancer patient, according to Schuchter.
For the molecular lab within Abramson Cancer Center, increased coronavirus testing has meant scaling back other laboratory testing such as viral titers for patients about to receive a bone marrow transplant. “The prioritization is not unique to coronavirus testing. In every area of medicine right now, we are asking, ‘Does the patient really need this or not?’” says Schuchter.
Within the Mount Sinai Health System in New York City, an in-house test became available just recently. The lab is now scaling up the number of tests it can conduct in a single day. Mount Sinai is following the New York City Department of Health guideline, telling patients who have mild symptoms to stay home and not seek testing. “Any person who has coronavirus symptoms should call their oncology team before coming to the center,” says Cardinale B. Smith, a palliative care physician, researcher and the director of quality for cancer services at Mount Sinai. “If a patient is on active cancer management and results of the test would alter cancer management, we then recommend coronavirus testing, which is being done at a tent outside the cancer center,” she adds.
As at the Abramson Cancer Center, patients at Moffitt are told to call their oncologist if they have symptoms of COVID-19. Eight patients at Moffitt had been tested as of March 25—all came back negative—and the results of five tests are still pending, according to Greene.
To increase COVID-19 testing in the U.S., the Food and Drug Administration is expanding the number of clinical laboratories that are allowed to conduct the test through its Emergency Use Authorization (EUA). One of these labs is ARUP Laboratories, a nonprofit national clinical reference laboratory in Salt Lake City, is using a coronavirus testing kit from a vendor that has received the EUA designation from the FDA. Currently, local hospitals, clinics and cancer centers send patient samples to ARUP for coronavirus testing, and the lab is working to accept samples from a wider geographic area in the near future. ARUP has been working with suppliers to secure needed supplies and reagents and is bringing in additional instrumentation to conduct the coronavirus diagnostics, with the goal of increasing its capacity to handle many more tests per day, according to Jay L. Patel, the medical director of molecular oncology and hematopathology at ARUP and also an associate professor at the University of Utah School of Medicine.
With rapid growth in the number of people infected with the virus in the U.S., the dynamics of testing for the coronavirus and how cancer centers are handling their everyday operations are changing. Aside from postponing screening procedures such as colonoscopies and some surgeries, Moffitt Cancer Center has had a normal volume of patient visits, says Greene. But on March 27, with the number of cases in Florida rising, Greene told Cancer Today, “Things are changing fast day by day now to limit elective visits.”
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